Download Houghton Prostate Cancer Screening

Prostate Cancer Screening
Bruce L. Houghton, MD
Associate Professor of Medicine
Division of General Medicine
Department of Internal Medicine
Creighton University School of Medicine
http://en.wikipedia.org/wiki/Image:Prostatelead.jpg
http://upload.wikimedia.org/wikipedia/commons/3/35/Male_anatomy.png
What is a Prostate?
• Small gland (about 3 to 4 cm diameter)
• A little larger than a walnut
• Secretes a slightly alkaline fluid that
combines with spermatozoa to create
semen.
• The prostatic alkaline fluid prolongs the
survival of the spermatozoa in the slightly
acidotic vaginal tract
Prostate
• Prostate needs testosterone to function
• Diseases of the Prostate
– Prostatitis (inflammation and/or infection of
the prostate)
– Benign Prostatic Hypertrophy (enlarged
prostate)
– Prostate Cancer
Prostate Cancer
• Leading type of cancer for U.S. men
• 1 in every 6 U.S. men will develop invasive
prostate cancer before he dies
• Second leading cause of cancer death in
U.S. men
– Following Lung cancer
• 2007
– 218,890 new cases diagnosed
– 27,050 men died of prostate cancer
Prostate Cancer
• U.S. Men have 1 in 6 lifetime chance of getting
prostate cancer
– But only 3% chance of dying of prostate cancer
• Autopsy series
– Detect Prostate Cancer in 1/3 of men younger than
80 years and 2/3 of men older than 80
• Suggests that prostate cancer is slow growing
and that men die of other causes before prostate
cancer is evident
Prostate Cancer Incidence
• Age-Adjusted Incidence (new cases) of
prostate cancer have increased over the
last 50 years
• Peaked 1990s
– Mostly with increased early detection due to
Prostate-specific antigen (PSA) testing in late
1980s
• Associated mostly with increased early
detection
Prostate cancer: changes over time average annual age-adjusted
incidence and mortality rates in the
United States, 1973 - 2001 (2001 US standard)
Source: SEER Program.
Prostate Cancer Risk Factors
• Increases with Age
– more common after age 50 years
• Increases with family history of prostate
cancer
• African-American men at higher risk
– Both of developing prostate cancer and of
dying from prostate cancer
Prostate Cancer Mortality
• Extent of tumor at time of diagnosis is
especially important
• Localized (cancer only within gland)
– 75% 10-year survival rate
• Regional Extension
– 55% 10-year survival rate
• Metastases
– 15% 10-year survival rate
http://nymag.com/daily/intel/31_giuliani_lg.jpg
Dan Fogelberg (expired age 56)
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Merv Griffin (expired age 82)
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Robert De Niro (diagnosed 2003)
http://www.celebritiesfans.com/showCELEB.php?celebID=1162
Why push for screening?
• Most early prostate cancer is
asymptomatic
• Symptoms of prostate cancer
– Sometimes similar to BPH symptoms
• Frequent urination, nocturnal urination, difficulty
urinating
– Erectile dysfunction or painful ejaculation
– Advanced cancer can cause bone pain
“Perfect” Prostate Cancer
Screening Test
• Identify asymptomatic men with
aggressive tumors early when the tumor is
localized
– Decrease mortality
– Decrease morbidity
• Urinary obstruction
• Prostate Cancer Metastatic bone pain
Prostate Cancer Screening
• Digital Rectal Examination (DRE)
• Prostate Specific Antigen Test (PSA)
• BPH
Cancer
Prostate Cancer Prevention?
• Vitamin E and Selenium
– Not enough evidence to recommend
• Finasteride (Proscar)
– Questionable
– Reduces risk of developing prostate cancer
by about 25%
– However aggressive cancers were diagnosed
more frequently in the first year in men who
took finasteride than who did not
Digital Rectal Examination
• Physician examines the prostate with a
gloved finger
• Detect enlargement of the prostate gland
• Asymmetry (enlarged lobe)
• Detect nodules (lumps)
• ?Normal consistency is similar to tip of
your nose?
http://www.abbottdiagnostics.com/Your_Health/Cancer-Oncology/images/cancer_prostate_04.jpg
http://www.hubbywishlist.com/images/fletch.jpg
How good is the DRE?
• Rarely done alone (PSA is often drawn as
well)
• Ranges of Sensitivity for DRE alone
– 18 to 22% up to 55 to 68% in asymptomatic
men
Prostate Specific Antigen (PSA)
• Glycoprotein produced by the prostate
epithelial cells
• Elevated PSA can precede clinical disease
by 5 to 10 years
• DRE has MINIMAL effect on PSA level
and PSA CAN BE drawn following a rectal
examination
What Will Elevate PSA?
•
•
•
•
BPH
Urinary retention
Acute Prostatitis
DRE
– 0.26 to 0.4 ng/ml
• Ejaculation
• Perineal trauma
– By up to 0.8 ng/ml
– Return to normal in 48
hours
• Procedures
– TURP
– Cystoscopy
– Prostate biopsy
Finasteride (Proscar)
Dutasteride (Avodart)
• Treatments for BPH
• Will LOWER the PSA about 50%
• ‘Double’ whatever level you get from a
patient on Finasteride or Dutasteride
PSA
• Traditional cutoff level is 4 ng/ml
• Other Ranges (not recommended by FDA)
– 40 to 49 years — 0 to 2.5 ng/mL
– 50 to 59 years — 0 to 3.5 ng/mL
– 60 to 69 years — 0 to 4.5 ng/mL
– 70 to 79 years — 0 to 6.5 ng/mL
Other PSA Tests you may hear
about
• PSA Velocity (measure PSA change over
time)
• PSA Density
• Free PSA
• Complexed PSA
What is the Harm of Screening?
• Anxiety (‘Labeling’)
• Unnecessary Prostate Biopsy
– If the PSA is elevated, most likely you will see a
Urologist
– Risk of complication less than 1%
• Overdiagnosis
– Diagnosed and treated for disease that may have
never caused significant problems
• Costs
• False Security
Prostate Cancer Treatments
• Surgery
• Radiation Treatment
• Hormonal Therapy
Other Resources
• www.patients.uptodate.com
What to Do?
• No convincing randomized controlled trials
that show prostate cancer screening
decreases morbidity or mortality from
prostate cancer
– Cochrane Database Syst Rev. 2006 Jul
19;3:CD004720
Two Large Prostate Cancer
Screening Trials Underway
• American Prostate, Lung, Colorectal, and
Ovarian Cancer Screening Trial
• European Randomized Study of Screening
for Prostate Cancer (ERSPC)
• Studies plan to pool their results
• Final data will not be available for years
What are Current
Recommendations for Prostate
Cancer Screening?
•
•
•
•
•
American Urological Association
American Cancer Society
American Academy of Family Practice (AAFP)
American College of Physicians
Canadian Task Force on Preventative Health
Care
• US Preventative Services Task Force (USPSTF)
American Urological Association
• Offer PSA Screening to men at age 50
years and who have an estimated life
expectancy of 10 years or more
• Men with first degree relatives who have
prostate cancer and African Americans
may benefit from screening at an earlier
age (usually in practice age 40)
American Cancer Society
• Both DRE and PSA be offered to men
aged 50 an older and who have a life
expectancy of 10 years or more
USPSTF, AAFP
• Insufficient evidence to recommend for or
against routine screening with PSA or
DRE
American College of Physicians
• Giving men information about the benefits
and risks/harms of screening to help them
make a decision based on personal
preference
Canadian Task Force on
Preventative Health Care
• Recommends against routine screening
with PSA
• Insufficient evidence to make a
recommendation on DRE
American College of Preventive
Medicine (Feb 2008 statement)
• Concurs with USPSTF
• Insufficient evidence currently to
recommend routine population screening
with DRE or PSA.
• Am J Prev Med 2008; 34 (2)
Urologist Willet Whitmore
• is cure possible in those for whom
it is necessary, and is cure
necessary in those for whom it is
possible?
• Urol Clin North Am 1990 Nov;17(4):689-97
So, What To Do?
• Speak with your physician
• Review the information on the website
• Decide what you want after weighing risks
and benefits of screening
Questions/Comments?